Death on the Installment Plan

Bleeding from his behind, Fidel Ramos had this crazy notion that he should be taken to a hospital. Not a prison infirmary, but a real hospital, with an emergency room and doctors and such.

His keepers at the Denver Reception and Diagnostic Center, a maximum security prison on Smith Road, thought otherwise.

Ramos complained that the bleeding was getting worse. No response. He asked for an ambulance. The guards chuckled. He demanded to make a call to his lawyer. That got someone's attention. Finally, after days of blood and negotiation, he was slung into the back of a van like a side of beef and taken to the emergency room at Denver Health.

At the hospital, Ramos lost consciousness. When he came to, a doctor explained that he'd performed surgery on a ruptured artery, a complication resulting from two prior surgeries to remove a peri-rectal cyst. If he hadn't sought medical attention when he did, the doctor told him, he could have bled to death.

It was around that time that Ramos decided he'd had enough. Maybe he was just a lowly prisoner, serving 24 years for bank robbery in the Colorado Department of Corrections. But you don't treat even a caged dog that way -- especially a dog whose complaints have already cost the state in excess of $100 million.

At 55, Ramos knows his way around the state prison system. He's been behind bars for close to half of his life. During that time, he's picked up a little knowledge of constitutional law, including the Eighth Amendment, the one about cruel and unusual punishment. (The Founding Fathers were against it.) Early in his prison career, he even made law.

In 1977, acting as his own attorney, Ramos filed a lawsuit against Colorado's antiquated maximum-security prison, known as "Old Max." The case soon became a class-action lawsuit championed by the American Civil Liberties Union, with Ramos named as lead plaintiff. A sprawling indictment of a violent, poorly managed corrections agency, Ramos v. Lamm was the most effective -- and costly -- attack on prison conditions the state had ever seen. It led to the closure of Old Max, a building boom that has modernized prisons across the state and a revolution in the way the DOC deals with safety issues and medical care for inmates ("Safely Behind Bars," July 3, 1997).

The Ramos case served as a judicial watchdog over the DOC until it was finally settled in 1994. By then, Ramos himself had moved on to federal prison. Three years ago he returned to the DOC to serve state time for his last robbery -- and discovered that medical care under the "new" system wasn't all that different from what he'd experienced previously. Although technologically the services were much more advanced, getting access to care wasn't easy.

For almost twenty years, Fidel Ramos had been the biggest pain in the ass the DOC had ever known. Now it was his turn to feel the pain.

According to Ramos, he had to battle the department's medical bureaucracy every step of the way -- to get his cyst diagnosed and operated upon, to get a second operation after the area became reinfected, and to get treatment for the ruptured artery in early 2001. Months later, he discovered in his medical records a doctor's recommendation that he not be forced to sit for prolonged periods of time, in order to avoid putting pressure on the incision. The recommendation had been routinely ignored as he was transported back and forth among half a dozen prisons between surgeries and afterward. Nearly two years after the last operation, he's still having trouble with chronic infections and bleeding -- and still being shifted from prison to prison.

"I'm tired of messing around with medical," he says. "There's professional concern and then there's professional neglect. They treat us like we don't deserve any kind of medical assistance at all."

Bouncing around the system for months, Ramos became convinced that his concerns were hardly isolated ones. He saw prisoners collapse or go into seizures while corrections officers with minimal medical training stood by, watching idly or putting in a leisurely call to medical staff for instructions. He saw jaundiced inmates, in advanced stages of hepatitis, dying slowly of liver disease while waiting for admission to the DOC's highly restricted drug-therapy program.

He saw Charles Renfro, an old con he'd known since the 1970s, confined to a wheelchair after suffering a stroke. One day Renfro complained of chest pains. He was told to put in a "kite" -- a formal request for administrative action -- so he could be examined by a physician's assistant the following day. That night, Renfro died in his cell.

Ramos saw plenty. Then he began drafting a new lawsuit, one he expects to be filed in federal court before Christmas.

If any enterprise in Colorado can be considered recession-proof, it's the corrections business. During the turbocharged 1990s, as newcomers flocked to the state and housing prices soared, the DOC's inmate population doubled and its annual budget nearly tripled. Now the local economy is sputtering, but the prisons are busier than ever.

Across the nation, a declining crime rate has slowed prison growth to a crawl. But the DOC's inmate population has increased by a whopping 50 percent in the past five years -- to 18,382 -- and is expected to soar to more than 22,000 in the next five years.

Other state agencies are slashing costs, cutting programs and laying off employees as part of Governor Bill Owens's belt-tightening measures. But the DOC is slated for a 7.5 percent increase in its current $500 million budget.

Longer sentences, an influx of drug offenders, a logjam of nonviolent prisoners that the state refuses to parole and other policy decisions have all contributed to the prison boom. Perhaps the biggest factor has been the increase in parolees being returned to prison for technical violations of their parole, including traffic offenses; close to one out of three people sent to prison last year were "technical returns," coming back to serve time on the same felony for which they were previously incarcerated. Whatever the driving force, the rising population comes with a rising price.

Part of that price is medical. Every time some crackhead, drunk driver, gangbanger or rapist is sent to prison, the taxpayer is also getting sentenced -- to pay for said felon's ulcers or peri-rectal cysts, insulin injections or dialysis for however long the offender is stuck in the system. In 1999, the DOC spent $30.5 million on medical services; this fiscal year, medical expenditures will top $54 million. Medical costs, along with mental-health and drug-treatment programs, are among the department's fastest-growing line items, demanding a greater percentage of the corrections budget than ever before.

Legally, the DOC isn't required to respond to every kind of health complaint a prisoner might raise; it is, however, supposed to address the "serious medical needs" of those in its custody. And thousands of prisoners now in the system have chronic, potentially life-threatening diseases that are devouring the medical budget -- including, most alarmingly, an epidemic of hepatitis C, a blood-borne virus that has infected 20 to 40 percent of the entire U.S. prison population.

The DOC estimates its current level of hep C infection at around 17 percent, well below the rampant spread of the disease in correctional systems on the East Coast. Even so, the virus, which attacks the liver and can cause cirrhosis and organ failure, is now the most common cause of death in Colorado prisons. A Westword review of death certificates, autopsy reports and other records found that at least twenty out of 122 inmate deaths -- roughly one out of six -- over the past three years stemmed from hepatitis-related illnesses. In recent months, hepatitis C has outpaced heart problems, lung cancer and other diseases as the leading killer in the joint.

Critics of the DOC's health-care system -- including inmates such as Ramos, plaintiffs' attorneys and prisoners' families -- insist that the quality of care is shockingly poor, resulting in unnecessary suffering and questionable deaths. The system's defenders insist that it meets and exceeds constitutional standards for inmate care. But the rising tide of deaths and lawsuits is prompting the department to re-examine how it deals with its sickest cases, from revising its controversial treatment policies for hepatitis C to opening a prison at Fort Lyon for geriatric and chronically ill inmates.

Facing a crisis in critical care that is only going to get worse in coming years, the DOC's medical staff is trying to steer a course between two extremes: a degree of compassion that it can't afford and a level of neglect that can be fatal.

"I think the department is acting in a responsible way," says Joseph McGarry, the department's chief medical officer. "We're taking care of 18,000 people. The fact is, being in a correctional system slows down your access to health care. Things don't happen as fast as they can on the street. That's part of the downside of being in prison."

Your name is Clarence Thompson. You are 28 years old, almost six feet tall, a sturdy 225 pounds. You are down for twelve years for theft and stuck in a private lockup in a place called Olney Springs. There is not much to do in the private lockup, but there is marijuana.

You get word that a drug test is coming down with your name on it. This is never good news, but especially not now, when you are higher than the razor-wire-topped fences that surround the place. A positive test means loss of "good time" -- time shaved from your sentence for good behavior. It also means restriction of privileges and a lot of other complications you don't even want to think about.

You've heard that there are special pills a body can take that are supposed to confuse the piss test, but you can't get any of that stuff in here. What you need is something else to clean out your system. Thanks to some very bad advice, or perhaps because your options are desperately limited, you seize on the only cleansing diet available to you.

You swallow Tide detergent and VO5 shampoo, washing the nasty stuff down with huge gulps of water. You follow this up with more and more water, to rinse your system clean. Results are not long in coming. Nausea grips you. Soon you are vomiting. The puking makes you thirsty, so you guzzle more water, then puke some more.

You keep this up most of the day, dodging the drug-testing squad. You think you are getting the dope out of your system, like flushing a radiator, but you are actually taking on water faster than your kidneys can eliminate it. You don't know that water intoxication can cause serious problems. Nobody told you what happens to the marathon runners, the Grand Canyon tourists, the psychotic compulsives and others who drown their thirst without replacing electrolytes -- how they sometimes become disoriented, fatigued, even gravely ill. You haven't heard about those rave-hopping, Ecstasy-addled kids who suck down water until their brain swells, cutting off its own oxygen supply, a condition that can lead to a coma and brain death.

By the time the authorities catch up with you that evening, you can't feel your legs. Maybe all the water sloshing inside of you will confuse the test, maybe not, but it's sure left you confused. You tell the medical staff you have taken something, but you won't tell them what it was. Noting your "deteriorating mental status" and suspecting a drug overdose, the staff finally calls for an ambulance.

You arrive at a Pueblo hospital after midnight. The electrolyte imbalance isn't detected until after you slip into a coma. You are rushed to intensive care, but it's already too late. The following morning, an electroencephalogram shows no brain activity. After several days, your family asks that your body be taken off life support, and you are officially pronounced dead at 1:09 p.m. on June 26, 2001.

Manner of death: accidental. Cause: probable acute water intoxication. In the course of the autopsy, various tests are performed.

Just as you feared, your urine tests positive for marijuana.

Prisoners die in all sorts of ways. The violent prison deaths you see in movies and TV shows -- stabbings, beatings, hangings, that suspicious "accident" in the license-plate factory -- are only a small part of the picture. The DOC averages one or two homicides a year, and just as few suicides.

Drug overdoses, accidental or not, aren't all that common, either. Occasionally, autopsies do turn up a lethal amount of heroin, morphine or some other controlled substance that's supposed to be impossible to obtain on the inside. (Note on the death certificate of one Arkansas Valley casualty: "Ingested three balloons filled with cocaine that ruptured.") But the ODs are not as frequent as you might think. The state's prisons had three such cases in 2000, two in 2001 and none at all in the first seven months of this year.

The vast majority of prisoner deaths aren't cinematic. Inmates get clogged arteries, diabetes, dementia. After protracted battles, they succumb to lung cancer, kidney failure, cirrhosis or AIDS. In some cases, the end comes amid such a muddle of diseases and complications that the coroner offers a catch-all phrase as cause: "failure to thrive."

Regardless of the cause, certain patterns have emerged that suggest dying inside is a very different matter from dying outside. Some prisoners perish of what appear to be very treatable medical problems, raising questions about the kind of health care they receive. And for the most part, they die young.

Although Colorado's prison population is getting older, with more inmates serving longer sentences, doing time is still chiefly a young man's fate. The average age of prisoners coming into the system in 2001 was right at 32 years old. The average age among prisoners who died last year was 48. By contrast, the average life expectancy of the non-incarcerated American male is 74 and rising.

Of course, most prisoners will do their time and get out alive. A statistician might argue that the relatively low age of those who die is largely a reflection of the demographics of the incarcerated; since there are more people in their forties and fifties than senior citizens behind bars, it follows that they account for a larger number of fatalities, too. But such a heavy concentration of "natural" deaths in such a narrow (and commonly survivable) age range can't be easily explained.

McGarry, the DOC's chief medical officer, attributes the early expiration of some prisoners to their dismal medical histories, which might include gunshot and knife wounds, alcoholism and drug addiction, as well as decades of little or no contact with the health-care system. A criminal lifestyle, he notes, is not conducive to a long and happy existence.

"People coming into our prisons are sicker and have had less medical attention than the rest of the folks out there," he says. "They have a much higher incidence of disease. There's a lot more trauma, a much greater history of abuse and substance abuse. In general, their income is less than any cross-section of the population, and studies have shown that the amount of money you make has a direct relationship to how long you live. For these people, it's almost like you move the biological clock up ten or fifteen years. A person who's forty in prison has the health of someone who's fifty or fifty-five."

Although prisoners complain frequently about the quality of health care they receive, in many cases it's probably better than what they're used to on the street. The DOC screens new arrivals for a panoply of infectious diseases, and most of those who are diagnosed with tuberculosis or hepatitis C were previously unaware that they had the disease.

"The DOC knows much more about the health of its patients than any HMO in the state," McGarry says. "We suffer the burden of our vigilance. We do a good job of detecting these diseases and treating them."

Yet there are crucial drawbacks to the kind of health care a prison can offer. Pundits who express outrage at the notion that prisoners are entitled to any kind of medical attention rarely grasp how limited the care really is. Routine complaints are usually seen by a nurse or physician's assistant rather than a doctor, and security considerations severely restrict access to outside care. Some rural prisons are located hours away from the nearest fully equipped trauma center. For obvious reasons, powerful painkillers are almost never prescribed, and all but the most indigent inmates are expected to purchase ibuprofen and other over-the-counter medicines at the canteen, paying for their pills out of prison wages that average less than eight dollars a month.

Depending on staff attitudes and training, a prisoner complaining of chest pains -- or labor pains -- may receive immediate treatment or be told to sit tight until tomorrow. Recently, the state paid $50,000 to one female inmate whose pregnancy ended in a miscarriage, the result of medical care that McGarry described as "below any minimal level of competency."

"In the real world, you can call 911 for a medical emergency," says one nurse-practitioner who's worked in Colorado's prisons. "But in there, you're at the mercy of the medical staff."

"The general medical services are poor," says Dennis Hartley, a Colorado Springs attorney who is currently suing the state over its hepatitis C treatment policies on behalf of several inmates. "But I don't think the DOC is completely at fault for that. Some inmates don't get treatment because they don't want to give blood tests that show they're getting drugs smuggled in. Some people arrive in pretty miserable condition to start with. But the general attitude on the medical staff is that the inmates are trying to manipulate them, and these guys have to make several complaints before they get the attention they need."

Sometimes they don't get it. Hartley once represented the family of a DOC inmate who was stabbed by another prisoner. "When the guards finally come to get him, they walk him to the infirmary," Hartley recalls. "Once he's there, they put him on a gurney -- and he's bled to death by that time. The pathologist said a simple pressure bandage could have prevented this."

Officially, the death was entered in the books as a homicide, but Hartley believes that medical care, or lack of it, played a part, too. The same might be said of death from an asthma attack -- a rare occurrence on the outside, but the DOC has had at least two such deaths in recent years.

Other cases are more ambiguous. Last December, 24-year-old Henry Whatley collapsed and died on a basketball court at the Buena Vista Correctional Facility. Whatley had a congenital heart defect; given his condition, it was an oversight for the DOC to place him at Buena Vista, a high-altitude setting that would put further strain on his heart. But then, Whatley probably shouldn't have been playing basketball, either.

In the spring of 2001, David Alonzo, 42, slipped and fell in his cell at Limon. Three days later he was dead.

Alonzo went to the infirmary the day after his fall, complaining of swelling in his left arm. He was moved to a local hospital, then to University Hospital in Denver, as the doctors who examined him began to recognize the seriousness of the infection he had developed. At University, Alonzo was diagnosed with upper-extremity compartment syndrome -- basically, his left arm had become necrotic and required immediate surgery. He died a few hours later.

It's impossible to say if Alonzo's bumped elbow would have proved just as fatal if he hadn't been in prison. He was diabetic and weighed 340 pounds; he had a history of health problems, and surgeons had previously amputated one leg below the knee. But when dealing with a condition as dangerous as compartment syndrome, every minute counts, and the long journey from infirmary to major hospital is, as McGarry puts it, part of the "downside" of prison life.

Bryan Bush never made it to the hospital. A 43-year-old inmate at Arkansas Valley, Bush was found unconscious in a bathroom in the summer of 2001 by another inmate. He was taken to the infirmary, where he revived. The medical staff could find nothing wrong with him and sent him back to his unit. He was found dead in his cell later that day.

Bush had a long history of seizures, and it was probably a seizure that killed him. That, at least, was the opinion of the forensic pathologist who conducted the autopsy and "found no evidence of traumatic injury or medical disease sufficient to explain his death." But among prisoners who knew Bush, a former minister and notorious child molester, rumors persist that he was murdered -- if not by another inmate (his cellmate was questioned and cleared), then by the contempt of his keepers.

Roderic Gottula, a former DOC medical director and now a consultant on correctional health-care issues, notes that most medical staffers who work in corrections "fell into it" rather than set out to find a job behind bars. Even so, he believes that Colorado's prisons usually deliver appropriate care in an environment hamstrung by security concerns and other challenges.

When Gottula left the system in 1995, he says, inmates were actually averaging twelve medical visits a year, far more than most people on the outside. "Obviously, they have an issue with illnesses that the average person doesn't have," Gottula explains. "But a lot of the visits aren't strictly medically related. If you want an extra mattress or different shoes, you go to medical. Sometimes they do it because they want to get out of work, check out the new nurse or try to get drugs. There's a whole variety of reasons."

But Gottula admits to being puzzled by the number of DOC deaths among younger inmates, particularly those deaths resulting from conditions that are usually non-fatal. "You don't see forty-year-olds dropping dead on the streets that often," he says. "Now, some of these guys have diabetes or other problems, but you don't see them dropping on the streets, either. You almost never see someone in the twenty-to-thirty age range die of these types of causes. This is really unusual."

Gottula wonders if the prison system is doing sufficient diagnosis and follow-up care of manageable illnesses. Even suicide, he suggests, reflects on the quality of health care, since suicidal prisoners typically see a health-care provider shortly before they try to take their lives. Last summer the DOC had a string of three suicides in four weeks. One was at San Carlos, the system's special prison for the mentally ill; the other two involved inmates who'd recently been moved from the state mental hospital in Pueblo back to regular prisons and killed themselves within days of the transfer.

"In that kind of situation, you'd expect they would be monitoring the inmate carefully to see how the transition was going," Gottula says.

Mental-health issues can play a part in other kinds of deaths, too. The DOC estimates that it has close to 2,500 prisoners with diagnosed mental illnesses, but only the most impaired end up at San Carlos. Others are supposed to be cared for in "special-needs" units at various prisons. But the care may not provide adequate protection for the mentally ill, who are often seen as easy prey by other prisoners. And it doesn't always protect staff from inmates who could be seriously deranged.

Consider the case of Edward Montour, a Limon inmate accused of killing corrections officer Eric Autobee with an oversized soup ladle in the prison kitchen in October.

The official version of the slaying, the DOC's first staff murder in more than seventy years, is that it came out of nowhere, a random assault by a "model" inmate who later admitted to investigators that he was seeking a transfer in order to avoid being labeled as a snitch. But Montour, who's serving a life sentence for the 1997 murder of his three-month-old daughter, also had a reputation within Limon as an unstable, often heavily medicated prisoner. Both inmate and staff sources say that kitchen workers had accessed inmate records and used the information found there to taunt Montour, who'd become increasingly agitated in the days leading up to the attack.

"If you taunt a convicted murderer and continuously call him 'Baby Killer,' among other things, most times the response is negative," says one Limon prisoner. "To involve other inmates in this game is dangerous."

"Montour should have been sent to a mental facility," says another. "When he first got here, they had him so pilled up he'd walk like Frankenstein to and from the pill line. There are lots of guys here with psycho jackets who should be in the state hospital, and he was one of them."

Your name is David Jenner. You are forty years old and serving what amounts to a life sentence -- 96 years -- for sexual assault. One day in 1997, a physician's assistant informs you that you've tested positive for the hepatitis C virus.

This is not, you are told, a big deal. The virus, which is spread primarily through dirty needles -- intravenous drug use, amateur tattooing -- can lurk in your system for years, even decades, with no visible symptoms. Most hep C infections become chronic, but only a small percentage of cases become deadly, progressing to cirrhosis or liver cancer. The DOC will monitor your blood, you learn, and if certain liver enzyme levels reach dangerously high levels, you could be eligible for treatment with a drug called interferon.

Over the next three years, you request and receive numerous blood tests that measure how your liver is doing. Each time you are told that you are faring just fine. But in 2000, you are transferred to the Limon Correctional Facility, and no one there seems particularly interested in your case. You ask for a blood test again and again, at least twenty times -- an average of twice a month for ten months. Your requests are ignored.

You persist. In October, you are given the test. A nurse tells you that your enzyme levels are not high enough to warrant drug treatment. You have been reading up on the disease, and the levels seem pretty high to you. You ask to review your medical file. When you finally get access to it, you realize that you have been misled.

According to the file, your enzyme levels have been increasing steadily for years, while DOC staffers told you merely that your counts were within the "acceptable" range. Actually, your enzyme levels were unacceptably high, by the department's own standards, as far back as 1999. But at some point, the medical staff hiked the values for the "acceptable" range by ten points without explanation, making you a borderline candidate, at best, for interferon therapy.

You apply for treatment. You are handed a contract that states you must first complete a year of substance-abuse counseling and random drug testing before you are eligible for interferon. No one told you about the classes before, and you wished you'd heard about them three years earlier. You sign the contract under protest. You do the classes and complete them in November 2001.

Now can you have the damn drugs? Of course not. The next step is a liver biopsy, which will give the doctors a better idea of how much damage the virus has already done. The biopsy is ordered in February but not scheduled until August 2002. "Budget constraints," you are told.

It's been five years since your diagnosis. You file numerous grievances, to no effect, and join several other prisoners who've been denied treatment for hepatitis C in a lawsuit against the state.

The doctor performing the biopsy is one of the defendants in your lawsuit. You wait in line with other prisoners until he calls you into his office. He explains that he'll "do a couple of passes," and if he can't hit the liver, he'll try again at a later date, with more sophisticated imaging equipment. He makes pointed reference to the fact that you are suing him.

You say little. You don't want to provoke someone who will soon be slicing into you.

You are given an anesthetic. You hear later that the doctor stuck you five or six times. Two months go by. You learn that the procedure failed to yield a single analyzable sample of liver tissue. You await another biopsy.

Your gut is swollen and achy, and you are fighting chronic symptoms of fatigue and nausea, as if you're getting the flu over and over again. The drug therapy is supposed to have close to a 50 percent success rate, but you are not close to getting the drugs. You file more grievances, write to your lawyer, compare notes with other prisoners on the insidious progress of the virus and the lack of progress in your treatment.

Mostly, you wait.

Prisoners die in all sorts of ways. Increasingly, though, they die from hepatitis C.

Last March, the virus claimed Frank Rodriguez, who'd been on Colorado's death row for sixteen years for the kidnapping, rape and murder of bookkeeper Lorraine Martelli. Rodriguez's death from liver failure saved the state the expense of an execution, but the disease's impact on the system is costing taxpayers millions.

The DOC has screened its inmate population for liver abnormalities since the 1970s, long before hepatitis C was identified as a specific threat. Over the years, as more has become known about the virus, the department has refined its treatment program and now offers a costly regimen of interferon and ribavirin, drugs that have proven successful in ridding the body of detectable levels of hepatitis C in up to half the patients treated.

But critics of the DOC's treatment policies say that out of hundreds who may need them, only a fortunate few actually receive the drugs. The system now has roughly 3,000 inmates who've tested positive for hep C; in the current fiscal year, 34 are receiving drug therapy. Even according to the DOC's own conservative estimates, which project that 4 percent of its hepatitis cases will end in liver failure, the number of cases getting treatment is abysmally low. And studies indicate that up to 20 percent of hepatitis C patients will develop cirrhosis; that's 600 potential candidates in the system right now.

The problem, says McGarry, is determining which inmates are the best candidates. "Do you treat 25 people in order to get the one who's at greatest risk?" he asks. "Undoubtedly, you're going to have to treat more than 4 percent. Our ability to identify and target those people isn't good enough."

But inmates say the department is trying to avoid treating anyone. They accuse administrators of loading the hep C program with hurdles and foot-dragging tactics -- the required year of substance-abuse classes, the delays in getting biopsies, restrictions that bar you from the program if you're too old, too close to your parole date or caught using tobacco -- in order to keep to a bare minimum the number of inmates receiving some very expensive drugs. Interferon therapy usually runs between 24 and 48 weeks, at an average cost of $25,000 per inmate. In some cases, the drugs' side effects require additional countermeasures, such as a series of injections to stimulate red and white blood cell production, bringing the total cost for each of those patients to as much as $75,000.

Terry Akers, an inmate at the Colorado State Penitentiary, learned that he had hepatitis C when his liver enzymes checked out "high" in 1998. But he was told his body seemed to be "fighting the infection adequately," and his treatment was delayed for months pending additional tests. Then he learned about the required classes, which weren't even offered at the time at CSP, the state's supermax. As the months dragged on, Akers developed cirrhosis and began vomiting blood. The DOC then denied his request for treatment because the disease had reached such an advanced stage, making it less likely that interferon would help him ("The Needle and the Damage Done," December 14, 2000).

Akers has endured a stomach swollen like a beach ball with excess fluid and debilitating cramps that have left him curled up on his cot, unable to walk. Earlier this year, he suffered a bout of encephalopathy that left him disoriented and incoherent for weeks. "No one expected me to make it," Akers wrote in a recent letter. "But I am determined to beat this disease."

Along with David Jenner and several other prisoners, Akers is now suing the state over its hepatitis policy. Another one of the plaintiffs, Anthony Rodriguez, has been seeking treatment for the virus within the DOC since 1993. For years nurses told him no treatment was necessary, based simply on examinations of his skin and eyes. After a blood test finally revealed his elevated liver enzymes, he waited another eighteen months for a successful liver biopsy. Although he qualified for interferon therapy, the drugs weren't ordered for another two and a half years -- and then Rodriguez learned he was receiving only half of the dosage that had been prescribed. Last year, medical staff decided that his infection wasn't responding to the drugs and ceased treatment while denying his request for an alternative drug regimen recommended by outside doctors.

The state's approach to the epidemic troubles Rod Gottula, who developed the DOC's initial hepatitis treatment policies a decade ago. "Back then, the treatment was in its infancy," Gottula recalls. "We didn't test routinely for hepatitis C. If we had someone who had an abnormal liver-function test, we would sometimes run a hepatitis profile on them and find it that way."

But the original policy didn't require a lengthy series of substance-abuse classes, either. Gottula is now the acting president of a national association of corrections health-care providers, and he says several states have adopted more "advanced" treatment programs than Colorado's, with fewer delays in detecting and treating the virus.

"Their treatment is more aggressive," he says. "Some of them require substance-abuse treatment, too -- but if they do, they make it available. From a physician's standpoint, it makes no sense to take a substance abuser with hep C and spend thousands of dollars on interferon and not treat the primary problem. The main issue I have with the recent DOC policy is that they required the substance-abuse program but didn't make it available; nor were people told that they needed the program to be eligible for interferon."

Gottula understands why some states are moving slowly in responding to the epidemic. "In many systems, just the cost of treating hep C is more than their whole health-care budget," he says. "So while they don't necessarily deny treatment, they don't go out actively looking for people to treat. When you get down to it, this is really a public health problem, and public health agencies don't want to fund it."

McGarry responds that his staff is diligent about informing patients that they have the virus and what their treatment options are; it's the inmate's responsibility, he insists, to take the necessary steps to qualify for drug therapy. "We're not dealing with a disease that can be spread innocuously," he notes. "You don't get hepatitis C from someone sneezing on you. The public health implications of this are different than they are for, say, tuberculosis. There's absolutely no downside to these people being involved in a drug or alcohol program, even if they aren't going to get [interferon] treatment."

But the current and threatened litigation surrounding hepatitis treatment appears to be exacting changes within the DOC. Hartley, the attorney representing Akers and Jenner in their lawsuit, declines to comment on the case other than to confirm that the litigants are in settlement negotiations. McGarry acknowledges that the department is in the process of revising its treatment protocol, with the aim of setting specific timelines for tests and biopsies and making drug therapy more readily accessible to qualified patients.

Even prisoners with advanced cirrhosis, such as Akers, can now qualify for the drugs, based on new research that suggests interferon can help stall the ravages of the disease. Akers reports that he started drug therapy a few weeks ago and felt immediate improvement. More recently, though, the drugs "caused my platelet and white blood cell counts to drop to critical levels," he says. He's now receiving injections to counter the side effects of the anti-viral drugs.

Treating hep C can be grotesquely expensive. But not treating it can be even more expensive. The virus is the primary reason for liver transplants in the United States. Last summer the DOC reached an agreement with the University of Colorado Health Sciences Center concerning inmates who might be candidates for transplants. Although no prisoner has yet been accepted for the procedure, which can cost around $250,000, McGarry acknowledges that it's probably only a matter of time until suitable candidates are approved. Death row inmates such as Rodriguez wouldn't be eligible, but dozens of others could conceivably meet the criteria.

"The DOC accepts financial responsibility for anyone we send to the university for liver transplantation," McGarry says. "If someone in our custody satisfies the transplant board, we will pay for that." The department has already paid for bone-marrow transplants for convicts with leukemia, he adds, as well as a kidney transplant for a diabetic woman who was on dialysis.

Some states have taken a different approach when faced with inmates who require organ transplants or other major medical procedures. They let them out, a practice known as "compassionate release" (or "patient dumping," as one California prison executive recently described it on Sixty Minutes). But Colorado has been reluctant to bend the terms of sentence for its hep C prisoners, even when the inmate's family offers to assume responsibility for his or her care. Prisoners are full of stories about cons who can't get treatment and can't get paroled, such as Arturo Guzman, a 34-year-old chronic drug offender who died in September after a long battle with hepatitis C. Despite his terminal condition, Guzman had been turned down for parole repeatedly, most recently in March.

Of course, most people couldn't care less about the health and welfare of addicts, rapists and killers. But Gottula argues that the public should start paying attention; the walls that separate the average citizen from convicts' epidemics are thinner than they appear.

"Most of these people aren't in there forever," he says. "The public ought to be interested, because these individuals are going to cycle back into our communities, with all their health problems and communicable diseases. And if most of them are in there for some drug-related activity, why aren't we working on that? We lock people up and don't take care of the primary problem."

Jailhouse lawyer Ramos says the public only hears about the lucky prisoner who gets a transplant or expensive drugs, not the swarm of medical problems in prison that go untreated. In his view, his keepers are no better than the care they offer to those they keep.

"Prisoners are looked at as less than human, but every human being has a right to live," he says. "If prisoners need treatment, they should get it. Instead, the people who run these places just sit back and watch them slowly die. To me, that's barbaric."